(no subject)

[rivka]

Lydia's taken on a practicum student - a graduate student at a nearby university looking for clinical training.

Actually, when I say "Lydia's taken on a practicum student," what I really mean is that Lydia's hired this person and then left her almost entirely without guidance. She's used to supervising interns, who have several years of clinical training and are able to work with minimal supervision. This new person has done some assessment practica, but has never seen a therapy case. And in fact, even the assessments she's done were structured and problem-focused: she went over lists of pre-selected questions and administered particular tests. And now Lydia's turned her loose in our clinics with minimal support, expecting her to do therapy.

It took me a long time to figure out what was happening. We were never in clinic at the same time - in fact, I'd barely met her. "I'm worried about her," Lydia would say to me in passing. "She seems reluctant to jump in."

Well, yes. That would probably be because she doesn't know what to do. Therapists don't spring fully-formed from the head of Zeus - someone needs to teach her. And it looks like that someone will be me.

We've had one supervision session so far, and she's also followed me around our new clinic while I see patients. I'm starting from the basics - way the basics, like "what should you plan to find out in an intake interview?" It seems to be helping. It's also kind of fun trying to break down what I do into its elementary components and verbalize my processes and strategies.

One of the things I want to do is pass on the legions of good advice I've received in the past. Sometimes that advice is technical: "Usually you shouldn't diagnose an Axis II [personality] disorder if the patient has a primary substance abuse disorder." Sometimes it's philosophical: "People come to therapy because they have become demoralized. It's the job of the therapist to instill hope." Sometimes it's medical: "If an HIV+ patient ever mentions that their vision has recently gotten blurry or they have spots floating in front of their eyes, it's a medical emergency."

And sometimes, the advice is simply practical. Here's a sampling of the best practical advice I've received:

1. Always leave the clinic by the back door. Never walk through the waiting room unless you're willing to stick around and see someone if they ask.

2. Never mind what your graduate program taught you about appropriate therapeutic boundaries - if you work in a medical setting, touch your patients. Your graduate program didn't teach your patients about appropriate therapeutic boundaries. If you refuse to touch someone with AIDS or cancer, they'll think they know why.

3. Relaxation training is the aspirin of behavioral medicine. Hardly anyone can't be benefited by a quick relaxation training session. It makes the patient feel good fast, and it makes you look like a genius. However, like aspirin, sometimes relaxation training has catastrophic effects. Know the signs and be prepared.

4. Never write anything in the chart that you wouldn't be willing to read to the patient. If you think this is an impossible task, probably one of three things is wrong: (a) you're making clinical judgments you can't back up with evidence, (b) you've lost empathy or perspective on the case, or (c) your chart notes are too detailed.

5. Never expect a doctor or a judge to read something longer than a page. Yeah, they should - but they probably won't. Make your report more concise.

and finally, and most valuable:

6. Don't look in the bucket. If you ever visit a patient who is holding a basin, or has a bucket at the bedside, don't look in the bucket.

You don't want to know.

Comments

[porcinea.livejournal.com]

Thank you for rule 6.